Emergency clinics pediatric emergencies in the first year of life


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Emergency clinics pediatric emergencies in the first year of life

  1. 1. Emerg Med Clin N Am 25 (2007) xi ErratumAirway Management in Trauma: An Update John McGill, MDa,ba Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue North, Minneapolis, MN 55415, USA b Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA The above article, which appeared in the August 2007 issue ‘‘CurrentConcepts in the Management of the Trauma Patient,’’ contained an unfor-tunate error in Fig. 2C. The correct representation of this figure appearsbelow.Fig. 2. (C) The bevel of the ET tube is facing posteriorly and allows for smooth passagethrough the glottis.0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.emc.2007.09.002 emed.theclinics.com
  2. 2. Emerg Med Clin N Am 25 (2007) xiii Erratum Acute Complications of Extremity Trauma Edward J. Newton, MD, John Love, MD Department of Emergency Medicine, Keck School of Medicine, LACþUSC Medical Center, Building GNH 1011, 1200 North State Street, Los Angeles, CA 90033, USA In the above article, which appeared in the August 2007 issue ‘‘CurrentConcepts in the Management of the Trauma Patient,’’ Dr. John Love’sname did not appear on the title page. We sincerely apologize for this graveerror, and fully recognize his important contributions to this article.0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.emc.2007.09.003 emed.theclinics.com
  3. 3. Emerg Med Clin N Am 25 (2007) xv Erratum Pediatric Major Trauma: An Approach to Evaluation and Management Jahn T. Avarello, MD, FAAPa, Richard M. Cantor, MD, FAAP, FACEPa,b a Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA b Central New York Poison Center, 750 East Adams Street, Syracuse, NY 13210, USA In the above article, which appeared in the August 2007 issue ‘‘CurrentConcepts in the Management of the Trauma Patient,’’ Tables 5 and 6 andBoxes 8 and 9 should have contained the following credit line: From Marx JA, Holberger RS. Rosen’s emergency medicine: concepts andclinical practice. 5th edition. Mosby; 2002. p. 267–81; with permission.0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.emc.2007.09.001 emed.theclinics.com
  4. 4. Emerg Med Clin N Am 25 (2007) xix–xx Preface Ghazala Q. Sharieff, MD, James E. Colletti, MD, FACEP, FAAEM, FAAP FAAEM, FAAP Guest Editors During the first year of life, children progress from a neonate, progress toan infant, and approach the toddler stage. They develop from individualswhose main functions are to smile spontaneously, feed, void and defecateto individuals who cruise, walk, speak (a few words), and have a pincergrasp. Not only do they develop through motor, language, and social skills,but also their physiologies and disease processes develop as well. Such as-sessment of a child in the first year of life can be challenging to even the mostexperienced clinician. This issue is dedicated to state of the art informationregarding the emergency care of the child during his or her first year of life.Current areas of interest, clinical practice, and controversy are addressed. Hyperbilirubinemia is a common occurrence in the newborn period. Neo-natal jaundice has shifted from an inpatient issue to an outpatient issue, andmanagement of hyperbilirubinemia is one of the most common reasons fornewborn readmission. Kernicterus, the feared complication of hyperbilirubi-nemia, was considered to be almost extinct but has reemerged recently. Be-cause of this, a review targeted to the emergency department presentation,evaluation, and management of the jaundiced newborn is included. Abdom-inal concerns are a common complaint in the emergency department. Chil-dren under a year of age may present with abdominal catastrophies withsubtle presentations. In the article on abdominal emergencies, an approachto the emergent pediatric abdomen during the neonatal and infant periods isdiscussed. Seizures are a common neurologic problem in childhood. In this0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.emc.2007.08.003 emed.theclinics.com
  5. 5. xx PREFACEissue of Emergency Medicine Clinics of North America, one article will differ-entiate seizures from other childhood disorders and focus on emergencytreatment, patient stabilization, termination of seizure activity, and determi-nation of seizure cause. Metabolic diseases can vary as much in clinical pre-sentation as it can in classifications. Neonates and infants who havemetabolic diseases frequently present with subtle symptoms that are similarto other emergencies. The article on metabolic illness discusses recognitionand management of specific disorders and specific laboratory entities includ-ing hypoglycemia, hyponatremia, and metabolic acidosis. The crying infantcan present a sense of anxiety and a diagnostic dilemma to the clinician;a discussion of differential diagnosis and management of the crying infantis included. In 2005, the American Heart Association updated the guidelinesfor newborn and pediatric resuscitation. These changes currently are beingtaught in Pediatric Advanced Life Support classes. One article reviews thepertinent changes in the care for the critically ill child. A detailed discussionof the newborn exam for background information complements all of thesearticles. We thank all of our authors for their time and effort in preparing thearticles. We also thank our loving spouses (Jeahan, and Javaid) and ourwonderful children (Jimmy, Mariyah, Aleena, and Grace) for their support,patience, and understanding during this endeavor. Ghazala Q. Sharieff, MD, FACEP, FAAEM, FAAP Palomar-Pomerado Health System/California Emergency Physicians San Diego, CA, USA and Division of Emergency Medicine Rady Children’s Hospital 3020 Children’s Way San Diego, CA 92123, USA James E. Colletti, MD, FAAEM, FAAP Department of Emergency Medicine Mayo Clinic College of Medicine 200 First St. SW Rochester, MN 55905, USA E-mail address: jamesecolletti@gmail.com (J.E. Colletti)
  6. 6. Emerg Med Clin N Am 25 (2007) xvii–xviii Foreword Amal Mattu, MD Consulting Editor ‘‘Children are not just little adults.’’ This simple phrase likely could beconsidered the unofficial motto of pediatric emergency physicians aroundthe world. The phrase has been uttered countless times by those who are in-volved in teaching pediatrics and pediatric emergency medicine, and it ishard to imagine that any medical student has graduated in the past severaldecades without hearing the phrase. There is wisdom within the meaning ofthe phrase: children are well known to present with atypical presentations ofcommon diseases, their size and physiology warrant alterations in drug dos-ages, and there are certain diseases that occur almost exclusively in youth.Children, therefore, must not be approached, worked up, or treated likeadults. But just as children are not little adults, neonates and newborns are notjust little children! Children in the first months and first year of life representthe extreme in terms of their atypical presentations, altered physiology, anddistinctive diseases. Certain unique endocrine, metabolic, and cardiac emer-gencies occur in the newborn period. The approach to hyperbilirubinemia inneonates is far different than the approach to hyperbilirubinemia at anyother time of life. Abdominal emergencies such as pyloric stenosis and mid-gut volvulus occur almost exclusively in the first months of life. Resuscita-tion issues are distinctive in the first month of life as well, so much sothat neonatal resuscitation and Neonatal Advanced Life Support coursesare taught at many institutions based on the model of the American HeartAssociation’s Pediatric Advanced Life Support course.0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.emc.2007.08.002 emed.theclinics.com
  7. 7. xviii FOREWORD In this issue of Emergency Medicine Clinics of North America, Drs. Shar-ieff and Colletti have assembled an outstanding group of experts in pediatricemergency medicine to address acute care of children in the first year of life.The editors and authors have addressed high risk conditions of the majororgan systems and common presentations that may harbor catastrophic ill-nesses. The reader will undoubtedly find the articles chock-full of pearls toimprove practice and pitfalls to avoid. Kudos go to the editors and authorsfor providing us an outstanding resource to improve our practice and thecare of this often perplexing patient population. Amal Mattu, MD Program Director Emergency Medicine Residency, and Associate Professor Department of Emergency Medicine University of Maryland School of Medicine 110 S. Paca Street, 6th Floor Suite 100, Baltimore Maryland 21201, USA E-mail address: amattu@smail.umaryland.edu
  8. 8. Emerg Med Clin N Am 25 (2007) 921–946 The Normal Newborn Exam, or Is It? Merlin C. Lowe, Jr, MD, FAAPa, Dale P. Woolridge, MD, PhD, FAAEM, FAAP, FACEPb,* a Department of Pediatrics, The University of Arizona, 1501 North Campbell Avenue, PO Box 245073, Tucson, AZ 85724-5073, USA b Department of Emergency Medicine and Pediatrics, The University of Arizona, 1515 North Campbell Avenue, Tucson, AZ 85724-5057, USA In today’s modern world of high technology imaging and sophisticatedlaboratory examinations, medicine has come to rely on technology muchmore than in the past. So much so that at times we forget about the powerof a thorough physical exam in detecting medical issues. In this article wewill explore the normal newborn examination, discuss the importance ofknowing normal versus abnormal findings and discuss some common andnot so common findings on the newborn examination. In healthy babies,15% to 20% will have at least one minor anomaly with an associated 3%chance of having a major anomaly. Two, three, or more minor anomaliesare found in 0.8% and 0.5% of healthy babies, respectively. In these casesthe chances of major anomalies rises to 10% and 20%, respectively [1]. Newborn infants may present to the emergency department for a varietyof reasons. Almost all of these derive from the parent’s perception thatsomething is wrong. In each of these cases, the role of the emergency phy-sician is to recognize abnormality and, if no abnormality exists, to alleviateconcerns of the parent. Mostly, parental concern stems from conditions thatare self-limited or are variants without physiologic consequence. Less com-mon are that these concerns are the presentation of a medical condition thathas the potential to worsen or represents underlying illness. Detection of thelatter can be life saving. Unfortunately, illness in the newborn is often subtleand difficult to detect. The primary difficulty lies in that the daily activities ofa newborn and the newborn’s interaction with the environment areextremely limited. It is therefore imperative that the emergency physicianbecomes familiar and comfortable with performing a newborn exam. * Corresponding author. E-mail address: dwoolridge@aemrc.arizona.edu (D.P. Woolridge).0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.emc.2007.07.013 emed.theclinics.com
  9. 9. 922 LOWE & WOOLRIDGE Performing a complete and thorough exam on an infant can sometimesbe monotonous where elements of the exam can be missed. Therefore, forthe benefit of the reader, Box 1 contains a checklist that can be used asa guide while performing such an exam. A complete physical examinationmay not be possible in the emergency department because of time con-straints. However, a systematic approach can allow a thorough examinationin a matter of minutes. Focus should be placed on the heart, lungs, andabdomen as well as a general sense of the wellness of the baby. The neuro-logical examination, in particular, is involved and often a complete neuro-logical examination is not necessary. Generally, testing two to three of theprimitive reflexes (such as the moro and sucking reflexes) and observingfor spontaneous movement of the limbs will give a good sense of the neuro-logical status of the child.General evaluation One of the greatest indicators of the wellness of a newborn is the generalobservation or gestalt that a clinician obtains by simply watching a babybefore the start of a physical exam. This can be done while observing thebaby in the basinet or in a parent’s arms. Signs of distress such as laboredbreathing, persistent crying, and so forth are often the first indicators ofan impending problem. The newborn infant will often be soundly asleepat the start of the examination and should be sleeping peacefully. Infantswho are moaning or grunting during sleep may have underlying illnessthat should be sought out. When awakened, it is important that the baby be vigorous and alert. Cry-ing should be energetic and strong. Watch for signs of listlessness and weakcries as harbingers of problems. A baby who does not appear vigorous canhave any number of reasons; all of which should raise concern. Watch the movement and positioning of a child. A newborn, full-termchild will lie with his or her upper and lower extremities flexed inwardthus showing good tone. A premature or impaired child is more likely tolie at rest with his or her extremities extended from the body showingdecreased tone. In addition, examine the movement of the extremities.Each limb should show spontaneous movement. Disuse of an extremitymay be the first indication of an underlying pathologic problem.Vital signs One of the most difficult parts of pediatrics is recognizing normal versusabnormal because of the great degree of variability in the ‘‘normal’’ rangesof values. This particularly holds true for vital signs. A list of normal rangescan be seen in Table 1. Other clinical indicators should be correlated withthe vital signs to aid in determination of significant abnormalities. For
  10. 10. THE NORMAL NEWBORN EXAM, OR IS IT? 923Box 1. The normal newborn exam: a head-to-toe approachA. Head Shape Fontanelle Lesions/swellingB. Eyes Red reflex Extraocular movement Pupillary shape/sizeC. Ears Positioning TagsD. Nose Nasal patencyE. Mouth Palate Dentition Oral lesionsF. Neck Swelling/cystsG. Chest Asymmetric chest rise with respirations Retractions Accessory respiratory muscle useH. Lungs Symetric aeration Breath soundsI. Heart MurmurJ. Abdomen Hepatosplenomegaly Cord vessels at birthK. Genital Inguinal masses Testicular/scrotal asymmetry Genital hypertrophy/lesions Rectal patencyL. Extremities Tenderness Extremity use/range of motion Additional digits/tags Hip clickM. Neurology Tone Suckling Palmar/pantar Moro
  11. 11. 924 LOWE WOOLRIDGETable 1Normal vital signs in the infant: normal ranges for specified vital signs are listed Heart Respiratory Systolic bloodAge rate rate pressureNewborn 90–180 40–60 60–901 mo 110–180 30–50 70–1043 mo 110–180 30–45 70–1046 mo 110–180 20–35 72–110 Data from Gausche-Hill M, Fuchs S, Yamamoto L. The pediatric emergency medicine re-source, revised. 4th edition. Sudbury (MA): Jones Bartlett; 2006. p. 108.example, a respiratory rate of 50 in a newborn who is sleeping comfortablyand showing no signs of retractions, and so forth, is likely ok; however, a re-spiratory rate of 50 associated with retractions, grunting, and nasal flaringindicates a neonate in respiratory distress. Temperature should always be included in the vital signs of newborns. Ithas been well documented that temperatures higher than 38 C are associ-ated with increased risk of serious bacterial illness in infants less than 2months of age. These include infections such as sepsis, meningitis, urinarytract infection, enterocolitis, and osteomyelitis. The latter two often havesymptoms that can lead one to suspect them. The first three can be more in-sidious. As a result, countless infants are hospitalized each year for a ‘‘ruleout sepsis’’ work-up to look for these infections. While a fever is a flag for infection work-up, one must always rememberthat newborns are just as likely to develop low temperatures or temperatureinstability in response to infections as well. Our newborn nursery uses tem-perature ranges from 36.5 to 37.5 C as a ‘‘normal’’ temperature for new-borns in the first several days of life. Swings above or below normalshould be a signal to evaluate the child closely for the possibility of an un-derlying infection or other problem. Hypothermia and hyperthermia may be indicators of sepsis; however,infection is not the only cause that should be pursued. Hypoglycemia, hypo-thyroidism, and hypoxia can also present with low temperatures. Hyperther-mia may be a manifestation of drug withdrawal, intracranial hemorrhage, oradrenal hemorrhage [2]. While fevers/hypothermia are indicators of illness, one must rememberthat infants are extremely susceptible to outside influence on temperature.A neonate may easily become hyperthermic as a result of an overly warmincubator, or may become hypothermic if left unwrapped in a cool room.After these issues are corrected, continued swings in temperature shouldyield an infection work-up. It should be noted that bundling an infantwill not produce an elevation in the core body temperature [3]. If bundlingis suspected as the source of a fever, a rectal temperature should bechecked. A rectal temperature higher than 38 C should prompt a sepsisevaluation.
  12. 12. THE NORMAL NEWBORN EXAM, OR IS IT? 925 Height, weight, and head circumference (Occipital Frontal Circumferenceor OFC) are critical to evaluate in the newborn. They can often give cluesabout other potential problems or abnormalities. In particular, weight is im-portant to evaluate. The average weight of a term neonate at birth is 3.4 kg.Standardized growth charts that can be used when making determinationsabout small or large for gestational age (SGA or LGA, respectively) infantsare available for download from http://www.cdc.gov/growthcharts. Infantsare considered appropriate for gestational age (AGA) if they are within 2standard deviations from the mean. It is important to know the gestationalage as accurately as possible, as 1 or 2 weeks’ difference can have significanteffects on SGA or LGA determinations. Gestational age can be estimatedbased on physical characteristics of the neonate including skin creases,external genitalia, ears, breasts, and neuromuscular development [2]. Oneshould also remember to adjust for prematurity when plotting weights of in-fants during an evaluation. This correction typically continues until thechild is 2 years of age. LGA or SGA status should alert the practitionerto evaluate the child carefully for other possible anomalies. Twenty percentof infants with serious congenital anomalies are SGA [2]. LGA infants may be large simply due to familial inheritance. Simplystated, large parents will often have large infants. Additionally, increasedmaternal weight gain during pregnancy may translate into an LGA infant.Of all causes of LGA, diabetes in the mother is most common. Infants are atparticularly increased risk if the mother’s blood sugars are poorly controlledduring the last trimester. (Of note, diabetes mellitus types 1 and 2 are linkedto significantly increased risk of perinatal mortality and morbidity [4]. Asso-ciated conditions include postnatal hypoglycemia, cardiac septal hypertro-phy, small left colon syndrome, and meconium plug, as well as others.) While being an infant of a diabetic mother is the most common cause ofLGA, there are several genetic syndromes that can cause babies to be LGA.Among them are cerebral gigantism (Soto’s syndrome), Beckwith-Wiede-mann syndrome, Simpson-Golabi-Behmel syndrome, and 11p trisomy.These syndromes all have their own characteristics and discussing them isbeyond the scope of this paper; however, it is important to consider suchsyndromes when assessing an LGA baby. For a more thorough discussionof syndromes and their associated clinical findings, one can refer to Smith’sRecognizable Patterns of Human Malformation [5]. OFC should be examined to assess for microcephaly or macrocephaly.The OFC can be particularly helpful when there is concern for hydroceph-alus. Macrocephaly can be an isolated finding or associated with otheranomalies. As an isolated finding, it is often familial with an autosomaldominant inheritance. When this is in question, the OFC of the parentscan be determined and plotted on nomograms. Nomograms for head cir-cumferences of 18 year olds can be used to extrapolate to the parents’OFC percentile. Head growth for infants with familial macrocephaly shouldfollow standard growth. While familial macrocephaly may be the cause, one
  13. 13. 926 LOWE WOOLRIDGEshould not assign this diagnosis without ensuring that other causes are notpresent. In particular, hydrocephalus is the most common cause of macro-cephaly and should therefore trigger an evaluation [6]. Hydrocephalus oftenpresents with widening sutures, full feeling, possibly bulging fontanelles, anda rapidly expanding OFC. Macrocephaly can also be associated with intra-cranial hemorrhage (eg, subdural or epidural bleeds), enlarged brain tissue(macrencephaly), or thickening of the skull bones [6]. Daily examinationwhile the neonate is in the hospital can identify widening suture lines ora fontanelle that is becoming more full and tense. These can be earlier indi-cators of a quickly enlarging head and thus an underlying pathologicproblem.Head The newborn head shows a great degree of variability in the ‘‘normal’’examination, as well as a large number of findings that are due to moldingin the vaginal canal and birth trauma. These normal variants and benignbirth trauma findings can make it difficult to find true pathological lesions. A brief review of anatomy reveals that the newborn skull is composed ofmany bones. The ‘‘neurocranium’’ (the portion of the skull that encom-passes the brain) is composed of eight bones. The facial skull is composedof 14 irregular bones. Most of these bones are not fused together at birthand are separated by fibrous webs, known as suture lines. Most physiciansare aware of the anterior and posterior fontanelles; however, there are a totalof six fontanelles. In addition to the two previously mentioned fontanelles,there are two pairs of lateral fontanelles known as the sphenoidal or antero-lateral fontanelles and the mastoid or posterolateral fontanelles. The fourlateral fontanelles generally fuse in infancy and are less clinically significant.The posterior fontanelle begins to close after the first few months and is gen-erally not appreciable by 1 year of age. The anterior fontanelle is generallyno longer palpable by 18 months of age [7]. Sutures are generally closed byage 12, but complete fusion continues until into the third decade [8]. Often, most commonly following vaginal birth, the newborn skull willshow a significant degree of molding. While this can be distressing to newparents, reassurance is the rule, as molding will resolve relatively rapidly, of-ten over the course of 3 to 5 days. The suture lines allow the bones to shiftduring the birth process. Often, they are molded into a cone shape allowingfor an easier passage of the head through the birth canal. Molding can besignificantly more pronounced after a long labor and delivery course. It isimportant to recognize molding as the OFC can increase by up to 1 cm asthe head shape resolves [2]. Localized edema of the scalp can occur following birth and is referred toas caput succedaneum. This is the most common scalp injury due to birthtrauma [9]. Caput succedaneum is particularly common after vaginal deliv-ery, but can occur following cesarean section delivery as well. This edema is
  14. 14. THE NORMAL NEWBORN EXAM, OR IS IT? 927generally serosanguinous, and occurs due to pressure on the head after beingconstricted against the uterus, cervix, or vaginal vault [2]. Vacuum-extracteddelivery commonly results in large caput areas because of the addition ofnegative pressure in the area of the vacuum attachment. Typical caput succedaneum size is only a few centimeters in diameter;however, they can be significantly larger. Spontaneous resolution is therule for caput succedaneum and, regardless of size, edema generally resolveswithin 48 hours [2]. Examination of the scalp will show a boggy, somewhatill-defined area that may cross suture lines. This feature helps distinguish ca-put succedaneum from another commonly found head lesion followingbirth, a cephalhematoma. Cephalhematomas result from injury to the blood vessel found in the sub-periosteal area. They can be distinguished from caput succedaneum in thatthey do not cross suture lines. Cephalhematomas occur in 1.5% to 2.5% ofall deliveries. Extraction deliveries are at a greater risk of developing a ceph-alhematoma with the incidence in forceps deliveries at 4.1% and vacuumextraction ranging from 9.8% to 14.8% [9,10]. Overly large hematomas orthose that persist may be the first indication of an underlying bleeding dis-order and should prompt evaluation. While caput succedaneum usually resolves in 48 hours, cephalhematomasmay take several days to weeks to fully resolve (further allowing them to bedistinguished from a caput). Cephalhematomas will resolve without inter-vention. Aspiration of the cephalhematoma is generally not indicated, asit leads to an increased risk of infection within the cephalhematoma [11].The exception to this is a cephalhematoma that is expanding, showing over-lying erythema, or having other signs of infection. While infection is rare, itcan occur, occasionally in association with scalp electrode placement. Here,aspiration may be required for diagnostic purposes. Less common, but important to consider, is a subgaleal bleed. Clinicalpresentation of subgaleal bleeds is generally described as the cranium havinga diffusely boggy or soft swelling of the scalp. While subgaleal bleeds mayoccur following difficult deliveries without extraction assistance, they mostcommonly will occur following vacuum extraction. Occurrence with vacuumextraction has been shown to be 59 (0.59%) in 10,000 births, compared with4 (0.04%) in 10,000 births via spontaneous vaginal deliveries without instru-mentation [12]. Infants delivered with vacuum extraction should be moni-tored with serial scalp exams for the development of a subgaleal bleed.These bleeds can be life threatening as large amounts of blood can fill thepotential space that lies between the galea aponeurosis and the periosteum.This space extends from the orbital ridges to the superior aspect of the neckand laterally to the ears. Mortality from these bleeds approaches 22% [13].Infants may require intravenous fluid support, blood transfusions, or anti-biotic management of infections that may establish themselves in the bleedarea. Additionally, because of the increased red cell breakdown, theseinfants are at risk of hyperbilirubinemia.
  15. 15. 928 LOWE WOOLRIDGE Normally, the bones of the head are separated by suture lines to allow formolding of the skull during birth as well as head growth. Head growth isprimarily driven by brain growth. As the brain grows, the neurocranium ex-pands to allow more room. Brain growth is at a tremendous rate in uteroand continues to rapidly grow during the first 3 years of life. At birth, theinfant brain is about 40% of adult volume. By age 3, it has reached nearly80% and by age 7 it is at 90% of adult size [8]. When a suture line is pre-maturely fused, termed craniosynostosis, the growth capacity of the skullin that plane is significantly reduced, but continues in the plane perpendic-ular to the fused suture. Craniosynostosis can occur in nonsyndromic and syndromic patterns. Itsincidence is 1 in 1700 to 2500 births and 1 in 25,000 births, respectively [14].Simple craniosynostosis involves a single suture, and compound craniosy-nostosis involves two or more suture lines. Most commonly involved isthe sagittal suture that is affected 40% to 60% of the time, followed bythe coronal (20% to 30%), metopic (less than 10%) and finally the lambdoidsuture. Isolated lambdoid synostosis occurs in approximately 3 of every100,000 births [8,14]. The major forms of hereditary craniosynostosis exhibit autosomal dom-inance, but can have a significant degree of variability in penetrance and ex-pressivity. Fibroblast growth factor receptors (FGFRs) have been shown tobe associated with suture formation and mutations in these genes have beenimplicated in several diseases. For example, mutations in the FGFR2 genecause Apert’s syndrome and Crouzon’s disease [15]. Much more common than craniosynostosis is positional plagiocephaly(simple cranial shaping). At first glance, lambdoid synostosis and occipitalplagiocephaly can look almost identical to each other. However, a thoroughphysical exam can readily distinguish between the two entities. The variancein head shape is best appreciated from above. With positional plagioce-phaly, the affected side will show forward positioning of the ear in responseto the bones being pushed forward by repeated positioning on the affectedside. In craniosynostosis, the affected side will have a posteriorly displacedear, because of failure of bone growth to move the ear forward to its normalposition. Mild plagiocephaly often can be treated with simple alternating ofthe baby’s sleep position such that the head is in a different position fromnight to night. More severe plagiocephaly may require a specially fitted hel-met to correct the misshapen skull. The helmet molds the skull bones backinto place as the skull grows by gently putting pressure on the areas that aremisshapen to move them back to correct alignment. After the initial fittingperiod the helmet is worn for 23 hours a day. For this to be effective, itshould be done before the sutures begin to fuse, ideally by age 4 to 6 months.Rarely, these devices may fail and surgical correction may be needed. If so,the optimal time to do so is before 1 year of age [16]. Fontanelle size is often not appreciated, but can be an indicator of under-lying pathology. Anterior fontanelle size is measured by averaging the
  16. 16. THE NORMAL NEWBORN EXAM, OR IS IT? 929anteroposterior and transverse lengths. Fontanelle size is influenced by braingrowth due to its stimulation of skull bone growth, suture development, andsubsequent osteogenesis [17]. On the first day of life, the average infant fon-tanelle size is varied from 0.6 cm to 3.6 cm [18]. A large number of disordersare associated with an abnormally large fontanelle. Most commonly, a largefontanelle is found in congenital hypothyroidism, achondroplasia, Downsyndrome, and increased intracranial pressure. Small fontanelles can be a sign of normal early closure, as 1% of fonta-nelles will close by age 3 months. Additionally, molding can make it difficultto appreciate a truly open fontanelle. However, a small fontanelle can be theharbinger of a pathologic problem and should be investigated. Typically,a small fontanelle is associated with microcephaly. It can be associatedwith craniosynostosis as previously discussed, but can also be seen withabnormal brain development, fetal alcohol syndrome, congenital infections,and many genetic syndromes [17]. Conversely, soft tissues within the fonta-nelle may shift depending on intracranial pressure such that bulging of softtissue within the fontanelle implies increased pressure within the craniumand sunken soft tissues implies dehydration.Eyes A pediatrician often examines the red reflexes of the eye at nearly everywell-child visit in search of the all elusive retinoblastoma. However, thered reflex can give much more information than simply screening fortumors. A white reflex, known as leukocoria, from the eye can be associatedwith many other conditions including cataracts, retinal detachment or dys-plasia, papillary membranes, and vitreous opacities. The differentialexpands much beyond this, and as such, findings of leukocoria require refer-ral to an ophthalmologist for further evaluation. Bear in mind that babieswith darker skin tones can have reflexes that do not look bright red; how-ever, they should not be white. In addition to examining for leukocoria,the clinician can look for colobomas, examine the pupillary reflex, andlook for strabismus using the ophthalmoscope. Retinoblastoma does, indeed, present with leukocoria. It is the most com-mon malignant intraocular tumor in childhood, with an incidence of 1 in17,000 [19]. It may present unilaterally or bilaterally, with 30% of cases be-ing bilateral. It is associated with mutations or deletions of the q14 band ofchromosome 13 [20]. Congenital cataracts are present from birth, by definition; however, theymay not be picked up until later in the first years of life. This is often becausesome cataracts are progressive and become larger with time. Congenital cat-aracts occur in 0.44% of live births, and account for 11.50% of blindness inpreschool [21]. Of these, 23% are inherited (most commonly autosomaldominant with complete penetrance) and as many as 60% of bilateral cata-racts are associated with metabolic (as in galactosemia) and systemic
  17. 17. 930 LOWE WOOLRIDGEdisease. Associated systemic diseases include congenital infections (rubella,toxoplasma, cytomegalovirus, and herpes simplex virus in particular), triso-mies (13, 18, and 21), hypoglycemia, and prematurity [22]. On physicalexam, one may see leukocoria, strabismus, nystagmus, light sensitivity ordecreased visual acuity (particularly later in life). Smaller cataracts may ap-pear as black spots in the red reflex. When examining the eyes for red reflexes, one may notice a dysconjugategaze. Gaze can be assessed by visualizing the papillary light reflex (using theophthalmoscope, but not looking through its lens). At birth, dysconjugategaze is not particularly concerning. Eyes may often be crossed or divergent.These findings generally correct without intervention by 2 months of age[23]. Dysconjugate gaze beyond this time frame may be an indication ofan underlying defect in the function of one or both eyes. Dysconjugategaze as a function of eye tracking is termed strabismus. In this condition,the weaker of the two eyes is typically patched to allow for appropriate de-velopment. In cases where strabismus is not corrected, visual acuity will belost in the weaker eye. This condition of lost vision is termed amblyopia. Following birth, subconjunctival hemorrhages are common. They repre-sent a burst blood vessel and do not present a danger to the infant. Theytypically reabsorb in 1 to 2 weeks. After birth, they can be caused by increas-ing intraocular pressure, such as through coughing or sneezing, or they mayoccur spontaneously. One should be aware that a subconjunctival hemor-rhage may be a sign of trauma that a parent may not have witnessed ormay not be forthcoming so the eye should be examined thoroughly for othersigns of injury. Blue sclera is often one of the telltale signs of osteogenesis imperfecta.While this is the most commonly thought of diagnosis, blue sclera can ap-pear in many different syndromes, including Ehlers-Danlos syndrome andHallermann-Streiff syndrome. In addition, healthy infants may have a bluishtint to the sclera since the sclera is thinner than in adulthood [21]. While examining the eye, it is important to examine the iris as well asthe sclera and pupil. The normal iris of neonates is typically blue or blu-ish-gray in light-skinned babies and can be darker gray or brown in infantswith darker skin [21]. The iris should be examined for colobomas, whichappear as a break in the continuity of the iris. Colobomas may be an iso-lated finding; however, they often are associated with other congenitalanomalies, so their presence should prompt a full examination and work-up for other findings [21]. Brushfield spots are areas of stromal hyperplasiasurrounded by areas of hypoplasia giving a speckled look to the iris. Thesecan be seen in healthy patients, but are much more common in those af-fected by Down syndrome. Upwards of 90% of Down syndrome patientswill have Brushfield spots [24], which can be seen in Zellweger’s syndromeas well. Nystagmus is repetitive, involuntary, rhythmic movements of the eye in aparticular direction. Several types of nystagmus exist, including horizontal,
  18. 18. THE NORMAL NEWBORN EXAM, OR IS IT? 931vertical, and rotary nystagmus. Nystagmus in neonates may be benign ormay represent a pathological process. It can be secondary to retinopathyof prematurity, prematurity itself, or normal physiologic reflexes. An entityknown as transient neonatal nystagmus typically develops before age 10months (mean 2.7 months) and resolves spontaneously by age 12 months.The cause is not yet determined [25]. When examining the eyes, one should be on the look out for opsoclonusin neonates. Opsoclonus is rapid, irregular, and nonrhythmic movements ofthe eyes. It should not be confused for nystagmus, which is a rhythmic beat-ing of the eyes. Opsoclonus shows beating in horizontal and vertical direc-tions. It may be seen in association with an acute febrile illness, especiallythose caused by Epstein-Barr virus, varicella, Coxsackie viruses, and WestNile virus [21,26]. When seen in conjunction with myoclonus, so calledopsoclonus-myoclonus syndrome, it has been associated with neuroblas-toma in 2% to 3% percent of cases [26]. Opsoclonus-myoclonus is oftenreferred to as ‘‘Dancing Eyes–Dancing Feet Syndrome’’ because of its clin-ical presentation.Ears Cranial molding from birth can move the ears into various positions, somolding should be taken into account when examining the ears. One shouldexamine the ears for their position, noting low-set ears, as this has beenassociated with several syndromes, and malformation of the auricle. Preaur-icular pits or skin tags are common, and often are hereditary. These are gen-erally inconsequential and no further work-up is needed when they are seenunless there is indication of other anomalies that are present. Hereditarypreauricular pits can be associated with deafness and this should be followedas the infant grows [2]. Additionally, ear anomalies can be associated withgenitourinary anomalies. As such a renal ultrasound is generally indicatedin these patients.Mouth Several variations of a normal exam present themselves in the mouth.These include natal teeth and Epstein’s pearls. In addition, one may seea cleft lip or palate. Natal teeth are defined as teeth that erupt at any pointbefore 30 days of life. These occur in about 1 in every 3000 births and almostalways involve the mandibular central incisors [27]. Structurally, they aresimilar to normal teeth; however, they generally lack a substantial root sys-tem. As such, they often fall out on their own at some point. There is noneed to have them removed unless there is concern for aspiration of thetooth should it come loose on its own, or if the tooth prevents proper feed-ing [28].
  19. 19. 932 LOWE WOOLRIDGE Epstein’s pearls and Bohn nodules are common findings in neonates.They are often yellowish or white and slightly raised, giving the appearanceof a pearl. Bohn nodules are located on the alveolar ridges, and Epsteinpearls are those located near the midpalatal raphe at the junction of thehard and soft palates [28]. They are remnants of embryonic developmentof the dental lamina and will resolve without treatment. Cleft lip and palate represent the most common anomaly of the head andneck in newborns. Individually and their various combinations are secondonly to club feet in regard to neonatal birth defects [29]. Cleft lip and palateare two distinct findings; however, the combination of the two is found morecommonly than isolated cleft lip or palate with 46% representing combinedcases, 21% isolated cleft lip, and 33% isolated cleft palate. Cleft lip carriesan incidence that varies with ethnicity ranging from 0.41 per 1000 in AfricanAmericans to 2.1 per 1000 in Asians. White ethnicities show an incidence of1:1000 [30]. The left lip is most commonly involved, followed by the right,then bilateral clefts. Surgical correction often produces very good cosmeticresults and should be considered early in cases of poor nutritional intakeand abnormal speech development. While most clefts are quite obvious upon examination, mucosal and sub-mucosal clefts can be less easy to identify visually. Generally, the clinician isable to palpate the cleft using a finger to examine the upper palate of theinfant.Neck Congenital muscular torticollis is the third most common musculoskele-tal anomaly of infants. It follows behind club foot and dysplasia of the hipand can have an incidence upwards of 1 in 250 live births [31]. The exactcause is unknown; however, it is known to be found more commonly inbreech and forceps deliveries. In approximately two thirds of cases,a mass can be felt in the affected sternocleidomastoid muscle. It presentswith the infant having its head flexed and the chin facing the directionopposite the affected muscle [32]. Occasionally, this contracture of the mus-cle can lead to plagiocephaly with abnormal placement of the eye and ear onthe affected side. Physical therapy is generally therapeutic. Rarely, surgicalrelease of the sternocleidomastoid muscle is needed [33]. If the torticollisis not corrected by age 1, plagiocephaly tends to be persistent [32]. The neck should be examined for any pits or other anomalies. These mayrepresent branchial cleft anomalies, cysts, or sinuses. These branchial archremnants will be found in the pinna of the ear, the preauricular area, orthe lateral neck When present, these anomalies may be associated with sys-temic syndromes such as Goldenhar syndrome, Pierre-Robin Association,Treacher-Collins syndrome, and Hallerman-Streiff syndrome [14]. A midlineneck lesion may represent a thyroglossal duct cyst or cervical cleft.
  20. 20. THE NORMAL NEWBORN EXAM, OR IS IT? 933Chest Clavicle fractures are one of the most common chest birth injuries, withan incidence of 0.2% to 3.5% [34]. They are identified by palpating crepitusin the clavicular region. Fractures can be confirmed by radiograph if neces-sary. No treatment is needed for clavicular fractures as they heal well, evenin the presence of significant angulation. When examining the lungs of a newborn, one should assess for symmetryand equal chest excursion as well as adequacy of air exchange. Examinationof the lungs includes assessment of the respiratory rate and other indicatorsof respiratory distress including nasal flaring, grunting, or retractions. Newborns will frequently exhibit transient tachypnea of the newborn(TTN), especially following cesarean section deliveries. It affects approxi-mately 0.3% to 0.5% of newborns and presents with tachypnea, increasedoxygen requirements, and a lack of hypercapnia on blood gas [35]. It isthought to represent delayed absorption of fluid in the lungs. Recovery isthe rule, although infants may need ventilatory assistance for a time period.Respiratory distress typically will present a few hours after birth andresolves in 24 to 72 hours [35].Cardiovascular The cardiovascular exam can be difficult in a newborn because of theiroften rapid heart rate. To briefly review neonatal physiology of the heart,one must have a basic understanding of fetal cardiac physiology. Beforebirth, the infant does not use the lungs for oxygenation. As such, pulmonarypressures are high and blood is preferentially shunted through the foramenovale and the ductus arteriosus to return to the systemic side of blood cir-culation. At the time of birth, many transitions must be completed, includ-ing closure of the foramen ovale and a decrease in pulmonary pressures toallow blood to flow through the lungs. The ductus arteriosus typically closes10 to 15 hours after birth. Full permanent fusion may take up to 3 weeks[36]. Auscultation of the heart sounds of a neonate typically reveals a single S1and a single, or very slightly split, S2 because of the continued relatively highpulmonary pressures. It can take up to 4 to 6 weeks for pulmonary pressuresto fully drop to their baseline [37]. As this occurs, the S2 becomes morephysiologically split. Typically, S1 is louder near the apex of the heartand S2 is louder near the base. An S3 may be heard near the apex and isconsidered normal. S4 is never normal in a newborn. Because of rapid heartrates, it can be difficult to truly distinguish the location of a gallop sound. Assuch, they are often referred to as a summation gallop. Palpation of peripheral pulses is important to perform in newborns.Weak femoral pulses in comparison with brachial pulses (especially of theright arm) can be an indicator of coarctation of the aorta.
  21. 21. 934 LOWE WOOLRIDGE Several murmurs can be heard at birth. These may or may not be inno-cent in nature. As the pressures in the pulmonary vasculature drop, a ductusthat remains patent (PDA) may begin to shunt left to right, creating a mur-mur often heard best just below the left clavicle near the mid clavicular line[36]. This murmur is typically not heard at birth, as the pulmonary pressureshave not yet dropped sufficiently to allow enough shunting to createa murmur. An innocent flow murmur, termed a newborn murmur, is commonlyheard at birth. It is characterized as a systolic ejection murmur located inthe left lower sternal border area that is vibratory in nature. This murmuris likely to represent rapid blood flow and is not considered pathologic. In-nocent flow murmurs typically do not radiate to other areas and are gradedas a I–II/VI in strength. One may hear a murmur from peripheral pulmonic stenosis (PPS) equallyin the left upper sternal border area, back, and axilla [37]. Typically thismurmur will be a soft, I–II/VI high-pitched systolic ejection murmur. PPSmurmurs typically resolve by age 2 as the sharp turns in the pulmonary vas-culature resolve. Other commonly described innocent murmurs include Still’s murmurs,pulmonary ejection murmurs, and venous hums. These murmurs, in con-trast to those previously described, are not typically heard in the newbornperiod. Innocent murmurs tend to have a vibratory sound. More harsh-soundingmurmurs should be evaluated to determine their etiology. Such harsh-sounding murmurs may represent valvular stenosis or regurgitation amongother pathological causes. Holosystolic murmurs are never innocent. Most commonly they repre-sent ventricular septal defects (VSD). They may also represent mitral or tri-cuspid regurgitation or more complex variations of VSDs, such asatrioventricular septal defects (AVSD). VSDs are the second most commoncongenital cardiac anomaly (falling only behind bicuspid aortic valves).They represent 15% to 20% of congenital cardiac defects [38]. A VSD mur-mur typically will be a harsh-sounding holosystolic murmur at the left lowersternal border. Smaller VSDs typically will have a louder sound as blood isforced across with a higher velocity. Importantly, VSD murmurs may not bepresent at birth because of elevated pulmonary pressures. As the pressuresdrop, the murmur becomes more pronounced. Certain anomalies associated with murmurs are also associated with sys-temic syndromes. For example, approximately 30% of patients with a com-plete atrioventricular septal defect will have Down syndrome [38]. Noonansyndrome is associated with a rare cardiac defectdsupravalvular pulmonicstenosis. The murmur of this anomaly is essentially identical to pulmonicstenosis, except that it is located slightly higher on the chest and an ejectionclick is not heard [37]. If a murmur is detected in the emergency departmentthat is concerning for pathology, evaluation is warranted. This should
  22. 22. THE NORMAL NEWBORN EXAM, OR IS IT? 935include a chest x-ray and an EKG. If abnormalities are found, the neonateshould be admitted for further evaluation. If no abnormalities are detectedand the child appears well, follow-up with a pediatric cardiologist as an out-patient is reasonable.Abdomen In examining the abdomen, the clinician should assess for typical abdom-inal components. This includes assessing for hepatomegaly, splenomegaly,and palpable enlarged kidneys. Abdominal palpation is best accomplishedusing the flats of the fingers rather than the tips, as they are more sensitiveto masses and so forth. The liver is often felt approximately 1 cm below thecostal margin. This degree of extrusion is considered normal. In general unless it is enlarged the spleen should not be detected by pal-pation. An enlarged spleen in the setting of prolonged or severe jaundiceshould alert the clinician to the possibility of a hemolyzing state, as maybe found in Rh or ABO incompatibility or other red cell morphologicaldefects such as spherocytosis or elliptocytosis. While attempting to palpate for an enlarged spleen, one can also palpatefor enlarged or cystic-feeling kidneys. Autosomal recessive polycystic kidneydisease can present with enlarged kidneys at birth [39]. Rarely, one can seecongenital absence of the abdominal muscles in combination with cryptor-chidism and urinary tract anomalies, termed Prune Belly Syndrome or theEagle-Barrett triad [39]. Prune Belly syndrome has an incidence of 1 in40,000 births, and 95% of cases are in males [40]. The umbilical cord should be inspected to ensure the presence of a singleumbilical vein and two umbilical arteries. A single umbilical artery (SUA) isfound in approximately 0.2% to 1% of newborns [41]. Studies have shownthat infants with an SUA have a threefold higher incidence of severe renalanomalies and a sixfold higher incidence of any renal malformation whencompared with the general population [42]. A scaphoid abdomen and respiratory distress at birth should raise con-cern for a congenital diaphragmatic hernia (CDH). When the possibilityof CDH exists, the infant should be intubated in an effort to prevent theswallowing of air that occurs with spontaneous breathing or with bag-valvemask ventilation [2]. Air in the intestines will lead to worsening respiratorydistress as the expanding intestines further compress the lungs and medias-tinum. It should be noted that absence of a scaphoid abdomen does not ruleout CDH. The differential diagnosis for hepatomegaly in a neonate is quite exten-sive. First, it is important to recognize true hepatomegaly. Hepatic sizecan be assessed by various means, including percussion of liver span andpalpation of the liver edge. When one palpates for the liver edge, it is recom-mended to start palpating in the lower quadrants to ensure that extremehepatomegaly is not missed. In general, a liver edge palpable beyond 3.5 cm
  23. 23. 936 LOWE WOOLRIDGEbelow the costal margin is considered enlarged. At 1 week of age, a normalliver span is 4.5 to 5.0 cm [43]. An enlarged edge below the costal margin inthe presence of a normal liver span may be caused by depression of the liverdownward due to lung hyperinflation or other anatomical causes. Once hepatomegaly has been ascertained, other important factors to noteare the presence or absence of jaundice, splenomegaly, and other physicalanomalies or systemic symptoms. These will help guide the examiner’swork-up to determine underlying causes.Genitourinary tract Several anomalies can be found when evaluating the genitourinary tract.As such, a thorough examination is important to identify any such findingsthat may exist. Neither girls nor boys are exempt from anomalies. Newborn boys should be examined for inguinal hernias, hydroceles, var-icoceles, undescended testes, or signs of hypospadias and other urethralanomalies. Inguinal hernias have an incidence of 0.8% to 4.4% in boys, rep-resenting one of the most common surgical issues for newborns [44]. Theycan present as a bulge in the inguinal area or may have palpable bowel inthe scrotum [45]. Inguinal hernias develop when the processus vaginalis failsto close, allowing enough of an opening to let bowel pass through. Approx-imately 60% involve the left side, 30% the right, and 10% will be bilateral[44]. When an inguinal hernia is identified, light, constant pressure should beapplied to the herniated bowel to reduce the bowel back into the abdomen.Occasionally, the bowel may become trapped and nonreducible. This repre-sents an incarcerated hernia and is a surgical emergency. Incarceration of aninguinal hernia may compromise blood flow to the intestines or the scrotalcontents resulting in damage to the end-organ. Girls are susceptible to ingui-nal hernias as well, although the male:female ratio is 6:1 [44]. Physical exam-ination generally reveals a lump in the inguinal area. When the processus vaginalis fails to fully close but allows only fluid topass into the scrotum a hydrocele results. Hydroceles are most commonlypresent at birth, although they rarely can arise later. Transilluminationcan be used to aid in the diagnosis of a hydrocele as they tend to easilyand uniformly light up, although bowel can occasionally transilluminateas well, making the distinguishing of the two difficult at times. Hydrocelesdo not extend into the inguinal canal. Typically they resolve within 12 to28 months, so surgical repair is generally deferred [44]. Varicoceles result from dilation of the pampiniform plexus and internalspermatic vein. Almost always, they occur on the left, and are often de-scribed as feeling like a ‘‘bag of worms.’’ Varicoceles are typically more eas-ily seen with the patient upright, as this increases the hydrostatic pressure onthe venous plexus. They should reduce easily or spontaneously with supinepositioning. Any varicocele that does not reduce or is located on the rightside should be evaluated by ultrasound, as failure to reduce is an indication
  24. 24. THE NORMAL NEWBORN EXAM, OR IS IT? 937of a possible blockage in venous drainage. This may be the result of an ab-dominal mass [45]. With typical varicoceles, surgical correction can beundertaken but such a need is debated as most are asymptomatic [39]. If cor-rection is desired, it typically is not done in the neonatal period. At birth, full-term boys will experience an undescended testis (cryptorchi-dism) about 3% to 4% of the time. By age 1, only 0.3% persist [39]. If onefails to locate a testis in the scrotum, examination of the inguinal canal areashould be performed. Often, testes are not truly undescended but are retrac-tile. These testes can be brought fully into the scrotum, although it may bedifficult. Retractile testes are the result of a hyperactive cremasteric reflexand will ultimately settle into the scrotum without intervention [45]. True undescended testes cannot be manually drawn into the scrotum onexamination. These will require intervention to draw the testes down intothe scrotum if they have not descended by 6 months of age. Typically thisis achieved by surgical orchiopexy but treatment with hCG can be attempted(success with hormonal treatment can reach approximately 30% to 40% butmore often failure results) [39]. Undescended testes should be brought intothe scrotum by intervention as this allows for better examination for malig-nancy as they have a 4 to 10 times higher risk than descended testes. Semi-nomas are most commonly seen [39]. Approximately 10% of those affectedwith undescended testes will have bilateral involvement. When bilateralundescended tests are seen, there should be suspicion of an underlyingcongenital adrenal hyperplasia with virilization of a female infant. This isparticularly true if hypospadias is also seen [38]. Ambiguous genitalia result from virilization of females or undermasculi-nization of males. The range of phenotypes can run from almost normalfemale to almost normal male anatomy. In boys, ambiguous genitaliacommonly result from problems in androgen synthesis (such as 17 alpha-hydroxylase deficiency) or end-organ resistance to these hormones (suchas in 5 alpha-reductase deficiency or androgen insensitivity). In girls,congenital adrenal hyperplasia (CAH) is the leading cause of ambiguousgenitalia. CAH occurs with an incidence of 0.06 to 0.08 per 1000 live births;90% of these cases are a result of 21-hydroxylase deficiency [46]. During examination of the genitalia, the clinician should evaluate forclitoromegaly, micropenis, bifid scrotum, or fusion of the labia resultingin a scrotum-like appearance [47]. Increased pigmentation of the skin canbe seen with CAH because of increased ACTH concentrations in an attemptto stimulate cortisol production.Extremities When examining the extremities, one should examine all four extremitiesfor anomalies. Both hands and both feet should be examined for absent orsupranumary digits. Polydactyly frequently is an isolated finding but may beassociated with other malformations. While spontaneous occurrences are
  25. 25. 938 LOWE WOOLRIDGEfrequent, a family history of polydactyly yields up to a 10-fold increase inoccurrences. Polydactyly of the fingers involving the ‘‘pinky’’ finger side isthe second most common anomaly of the hand with an incidence of 1 in3000 [48]. Involvement can range from a simple skin tag that can be removedby tying a suture at the base to a fully formed digit including bony struc-tures. These more complex digits require surgical removal. While they rarelyproduce a functional deficit, cosmetic reasons often lead to removal. Surgeryis generally performed between 1 and 2 years of age [48]. Polydactyly of thetoes commonly occurs as well. Surgical correction, if needed, for supranu-mary toes generally occurs between 6 months and 1 year. The palms of the hands should be examined for the presence of a singletransverse palmar crease. While a single palmar crease is associated withseveral syndromes, most notably Down syndrome, approximately 4% ofthe healthy population will have a unilateral single palmar crease and 1%will have bilateral single transverse palmar creases. Talipes equinovarus, commonly known a clubfoot, is a relatively com-mon deformity with an incidence reported at 1 in 1000 live births. Bilateralinvolvement occurs in 30% to 50% of cases. Male to female ratios are 2:1[48]. Clubfoot is a complex anomaly. It is composed of four main components:(1) the forefoot is inverted and adducted, (2) the heel and hindfoot are in-verted, (3) limitation of extension at the ankle and subtalar joint, and finally(4) internal rotation of the leg [49]. Physical examination reveals inability tobring the foot fully to midline. Initial correction is attempted with serialcasting. Progressive casting is successful in most patients; however, insome cases, surgery may be required [49]. If needed, surgery is generally per-formed between 6 and 9 months.Neurological An extensive neurological examination can be quite time consuming;however, all infants should receive at least a limited neurological examina-tion including tone, primitive reflexes, and a gross assessment of muscu-lar/sensory status and cranial nerves. A list of primitive reflexes anda short description of each can be found in Box 2. As in older children, a sys-tematic approach is helpful. Often one can begin with a general assessment,followed by cranial nerves, motor function, sensory function, and reflexes. Agood assessment of neurological status can often be obtained simply bycareful observation of the infant. One should observe movements of theface for symmetry. Arms and legs should be watched to assess for movementor lack thereof. At birth, full-term infants show a flexed posture of theextremities and have the ability to raise their heads in the vertical midlineplane, although they may still be quite unsteady [50]. Movements of theextremities should be generally smooth without a significant amount of jerk-ing. The cry should be strong and vigorous. Often neurological problems
  26. 26. THE NORMAL NEWBORN EXAM, OR IS IT? 939Box 2. Common Primitive ReflexesRooting ReflexTouch newborn on either side of cheek and baby turns toward stimulus.Walking ReflexHold baby up in vertical position. As feet touch ground, baby makes walking motion.Tonic Neck (Fencing) ReflexRotate baby’s head leftward and the left arm stretches into extension and the right arm flexes up above head (opposite reaction if head is rotated rightward).Moro Reflex (Startle Reflex)Hold supine infant by arms a few inches above bed and gently release infant back to elicit startle. Baby throws arms out in extension and baby grimaces.Hand-to-Mouth (Babkin) ReflexStroke newborn’s cheek or put finger in baby’s palm and baby will bring his fist to mouth and suck a finger.Swimmer’s (Gallant) ResponseHold baby prone while supporting belly with hand. Stroke along one side of spine and baby flexes entire torso toward the stroked side.PalmarStroke inner palm/sole and toes/fingers curl around (‘‘grasp’’) examiner’s finger.PlantarStroke outer sole (Babinski) and toes spread with great toe dorsiflexion.Doll’s EyesGive one forefinger to each hand (baby grasps both) and pull baby to sitting with each forefinger. Eyes open on coming to sitting (like a doll’s).Protective ReflexSoft cloth is placed over the baby’s eyes and nose. Baby arches head, turns head side to side, and brings both hands to face to swipe cloth away.Crawling ReflexNewborn placed on abdomen and baby flexes legs under as if to crawl.
  27. 27. 940 LOWE WOOLRIDGEwill produce an altered cry such as a weak cry or a particularly high-pitchedcry. Cranial nerve (CN) assessment can begin with the eyes. By 28 weeks aninfant’s neurological system has developed enough to produce a blinkwhen a bright light is shone in the eyes (CN II and VII). Between 28 and32 weeks the papillary reflex develops (CN II and III) [2]. CN V can betested via corneal reflex or with light touch/pin prick to the trigeminalbranch areas producing a withdrawal from the stimulus. Additionally,full-term infants can often fixate and track on large objects thus allowingfor testing of CN II, III, IV, and VI. It should be noted that a dysconjugategaze is not abnormal when a neonate is not fixing on an object [2]. Facialasymmetry may indicate a lesion involving the facial nerve. Loud noisesshould evoke a blink, testing CN VIII. The swallowing reflex tests CN IXand X. Fasciculations of the sternocleidomastoid muscle or tongue may rep-resent a lesion involving CN XI or XII, respectively [2]. Detailed examina-tion of the cranial nerves is generally not necessary unless there is suspicionof a problem. Sensation testing is generally limited to light touch and pinprick testing.During the entire newborn exam, the clinician can be assessing the responseof the baby to touch. For example, infants commonly will react to thestethoscope touching their chest. Motor examination involves assessing spontaneous movement of thehead and extremities, as well as muscular tone. Neonatal hypotonia is themost common abnormal neurological sign seen in neonates [50]. It is asso-ciated with a wide array of disorders. Hypotonia can be divided into centraland peripheral origins. Central hypotonia tends to be associated with othercentral nervous system (CNS) findings. Failure to fixate or meet other mile-stones, or seizures, are associated with central hypotonia [51]. Several com-mon syndromes are associated with hypotonia include Down Syndrome andPrader-Willi syndrome. Other important considerations are hypoglycemia,hypothyroidism, hypoxic-ischemic encephalopathy, infection, and metabolicdisorders. Often, central causes of hypotonia become more classic of CNSlesions resulting in increased tone, increased reflexes, and so forth. Transec-tion of the spinal cord should also be considered, especially when there isa report of possible neck hyperextension in utero or during delivery. Theseinfants may present severely with respiratory failure. Lower spinal levellesions may present with hypotonia that often becomes hypertonia withhyperreflexia characteristic of central CNS lesions [51]. Peripheral hypotonia, in contrast with central causes, often will present ashypotonia without any specific central signs. Eyes are able to fix well. In-fants often are responsive to sounds and stimuli. Examples of this includespinal muscular atrophy, neonatal myasthenia gravis, and infantilebotulism. Infant spinal muscular atrophy, also known as Werdnig-Hoffman syn-drome or SMA type 1, can present with hypotonia at birth (in 60% of
  28. 28. THE NORMAL NEWBORN EXAM, OR IS IT? 941cases), weakness, poor suck, and absent reflexes. This is due to anterior horncell degeneration. Werdnig-Hoffman typically presents between 0 and 6months [52]. In contrast to cerebral damage hypotonia, these infants aretypically alert and have facial reactions. Neonatal myasthenia gravis occurs in 10% to 15% of infants born tomothers with myasthenia gravis. The acetylcholine receptor antibodies read-ily cross the placenta and can attach to the infant’s receptors producinga myasthenic phenotype. Signs of bulbar weakness including a weak suckand cry, hypotonia, absence of a moro reflex, and respiratory insufficiencycan develop up to 72 hours after delivery. Treatment is with acetylcholines-terase inhibitors as in adults. Symptoms generally resolve by about 12 weeksof age as the maternal antibodies are cleared. During delivery, particularly with difficult or breech deliveries, the bra-chial plexus may be injured causing a spectrum of resulting outcomes.The brachial plexus is formed from the C5-T1 nerve roots. Palsies involvingthis plexus are divided into three main types. Erb palsy involves the C5, C6,and occasionally C7. Klumpke palsy involves C8 and T1. The third typeinvolves the complete plexus. Erb palsies present with the affected upperextremity in the classic ‘‘waiter’s tip’’ position. Klumpke palsies yield a par-alyzed hand with full function of the elbow and shoulder. This palsy is rare,comprising only 0.5% of all brachial plexus injuries [2]. Total plexus injuries yield a complete paralysis of the upper extremity. In-juries may be transient in mild cases to permanent in more severe instances.The range of resolution relates to the actual injury to the nerve roots. Mildcases generally are the result of the brachial plexus nerve roots beingstretched, termed neurapraxia. In these cases, prognosis is excellent. Themost severe cases result when the nerve root is avulsed from the spinalcord, known as axonotmesis. These cases have no chance for spontaneousresolution and surgical correction often does not yield good outcomes [2].Fortunately, 80% to 95% of cases (primarily Erb palsies) will resolve spon-taneously over the course of a few weeks to months. If, on physical examination, there is difficulty determining if the infantdoes not move the area because of pain (as a result of a clavicular fracture,for example) or a palsy, the Moro reflex can be used. In cases of palsies, theMoro will result in asymmetric movement.Skin Newborn babies exhibit a plethora of skin findings. Often, these findingscan be alarming to parents and result in numerous clinic and emergency de-partment visits. Often, visual diagnosis is quite easy and can alleviate paren-tal concerns. Newborns often experience some degree of vasomotor instability that canpresent in several ways, including cutis marmorata, harlequin color changes,and acrocyanosis. Cutis marmorata is a condition resulting from uneven
  29. 29. 942 LOWE WOOLRIDGEdistribution of capillary blood flow. It gives a mottled appearance to theskin and often can be induced by cold exposure. Harlequin color changes are precipitated by turning the baby on the side.When this is done, the lower half of the baby becomes erythematous ordusky while the upper half becomes pale. Often there is a sharp demarcationbetween zones. This typically resolves within a few seconds after returningto the supine position but can persist for up to 20 minutes [53]. Harlequincolor changes are more commonly seen in low-birth-weight infants andoften resolve after the first few weeks of life. Acrocyanosis results from venous blood pooling in the extremities givinga bluish color to the hands, feet, and occasionally around the lips. This con-dition is exaggerated with cool temperatures and resolves with warming.Acrocyanosis is not pathological and will resolve as vasomotor stabilityimproves. Erythema toxicum is extremely common, affecting up to 50% of full-terminfants [53]. It typically presents in the first 2 to 3 days of life and typicallyresolves in 5 to 7 days. Lesions classically are described as having a centralflesh-colored papule with surrounding erythema at the base. Numbers canrange from a few lesions to over 100. With many lesions, the erythemacan become confluent making the appearance less classic, but examinationof the margins often reveals individual papules with the typical appearance.Biopsy is generally not needed but would show the presence of eosinophils.Its etiology is not well known at this point. Less common is neonatal pustular melanosis, which affects approxi-mately 5% of black infants and less than 1% of white infants [2]. The pus-tules are always present at birth or form within the first 24 hours of life.Following pustule formation, the pustules rupture leaving the classic collar-ettes of scaly skin and hyperpigmentation. It is possible for the pustules torupture in utero leaving only the collarettes and hyperpigmentation at birth.Pustules may be present on the face, neck, hands, and feet (including thepalms and soles). Atypical presentations should be evaluated very closelyas some infectious processes, such as impetigo, can mimic pustular melano-sis and require rapid treatment [2]. Forty percent of newborns will have milia, most commonly found on thenose [53]. They represent small cysts filled with keratinocytes and sebaceousdebris. They may also be seen on other areas of the body. Generally, thesepapules are self-resolving over the course of a few weeks. Epstein’s pearlsrepresent the same process in the oral cavity. Neonatal acne is occasionally seen shortly after birth but typically de-velops between the second and fourth week of life. It peaks around 8 to12 weeks of life, under the influence of maternal and fetal androgens, thensubsequently resolves. Lesions are characteristically comedonal or pustularin appearance. Occasionally, nodulocystic acne can occur. In these cases,medical management may be indicated to prevent scarring. Persistent acnemay be an indication of excess androgen production. If there are concerns
  30. 30. THE NORMAL NEWBORN EXAM, OR IS IT? 943about this, growth should be followed closely and a bone age can be checkedfor accelerated bone growth. Normal bone growth makes excess androgenproduction unlikely [2]. Nevus simplex is a blanching macule that is typically pink or red in color.When located on the glabella they are commonly referred to as angel kisses,and when located on the posterior neck they are often termed stork bites.While these two sites are the most common, they may be found anywherealong the midline from the eyes to the nape of the neck. Often they fadewith time, although they may not completely. Nevus simplex should be distinguished from a nevus flammeus or ‘‘port-wine stain.’’ Port-wine stains do not tend to resolve much spontaneously.Laser treatment can help reduce their appearance. They are important torecognize, as they are associated with some syndromes. In particular, a nevusflammeus that involves the ophthalmic and maxillary regions of the trigem-inal nerve (unilaterally or bilaterally) may be associated with Sturge-Webersyndrome that can have CNS involvement and lead to seizures. Port-winestains that involve the face and/or upper extremity with hypertrophy ofthe affected side may have a condition termed Klippel-Trenaunay [2]. Dermal melanoses, formerly referred to as Mongolian spots, are bluish-black areas of hyperpigmentation often found on the buttocks, back, andshoulders. They are extremely common in darker skinned babies (upwardsof 90% of Native American, Asian, and African American babies will havethem) [53]. These spots can be confused with bruising and have resulted inevaluation for abuse in some cases. For this reason it is important to recog-nize them. Typically they will fade with age but may persist into adulthood. ´ Another commonly seen hyperpigmented macule is the cafe au lait spot. ´Typically these macules are light brown in color. A few cafe au lait maculesare normal; however, the presence of many macules or a very large maculemay indicate the presence of a systemic disease such as neurofibromatosistype 1 or McCune-Albright syndrome, respectively. The following list sum-marizes the National Institutes of Health criteria for the diagnosis of neuro-fibromatosis type 1 [54]. Any two or more clinical features are required fordiagnosis. Six or more cafe-au-lait macules over 5 mm in greatest diameter in pre- ´ pubertal individuals and over 15 mm in greatest diameter in postpuber- tal individuals Two or more neurofibromas of any type or one plexiform neurofibroma Freckling in the axillary or inguinal regions Optic glioma Two or more Lisch nodules (iris harmartomas) A distinctive osseous lesion such as sphenoid dysplasia or thinning of the long bone cortex with or without pseudarthrosis A first-degree relative (parent, sibling, or offspring) with neurofibroma- tosis type 1 by the above criteria
  31. 31. 944 LOWE WOOLRIDGESummary Despite the broad technologic advancements of medicine, screening forillness in infants is highly reliant on a complete physical examination. Forthis reason it is critical that the examining physician not only have a thor-ough understanding of abnormal findings but also the normal findingsand their variants. The vast majority of infants are healthy and findings pre-dictive of future health problems are subtle and infrequent. Yet, outcomescan be devastating. Therefore it is critical for the physician to remain dili-gent during screening. It is our hope that this article will assist the physicianin this task and allow for more accurate and timely diagnosis that preventsor minimizes long-term health problems in children.References [1] Thilo EH, Rosenberg AA. The newborn infant. In: Hay WW, Levin MJ, Sondheimer JM, et al, editors. Current diagnosis and treatment in pediatrics. 18th edition. New York: Lange Medical Books/McGraw-Hill; 2007. [2] Bland RD. The newborn infant. In: Rudolph CD, Rudolph AM, Hostetter MK, et al, editors. Rudolph’s pediatrics. 21st edition. New York: McGraw-Hill; 2003. p. 55–222. [3] Grover G, Berkowitz CD, Lewis RJ, et al. The effects of bundling on infant temperature- Pediatrics 1994;94(5):669–73. [4] Macintosh MC, Fleming KM, Bailey JA, et al. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population-based study. BMJ 2006;333(7560):157–8. [5] Jones KL. Smith’s recognizable patterns of human malformation. Philadelphia: Saunders; 1997. [6] DeMyer W. Normal and abnormal development of the neuraxis. In: Rudolph CD, Rudolph AM, Hostetter MK, et al, editors. Rudolph’s pediatrics. 21st edition. New York: McGraw-Hill; 2003. p. 2174–9. [7] Moore KL, Dalley AF. Introduction to clinically oriented anatomy. In: Moore KL, Dalley AF, editors. Clinically oriented anatomy. Philadelphia: Lippincott Williams and Wilkins; 1999. p. 2–58. [8] Kabbani H, Raghuveer T. Craniosynostosis. Am Fam Physician 2004;69(12):2863–70. [9] Hillenbrand KM. Birth trauma. In: Perkins RM, Swift JD, Newton DA, editors. Pediatric hospital medicine. Philadelphia: Lippincott Williams and Wilkins; 2003. p. 592–6.[10] Caughey AB, Sandberg PL, Zlatnik MG. Forceps compared with vacuum: rates of neonatal and maternal morbidity. Obstet Gynecol 2005;106(5 Part 1):908–12.[11] Blom NA, Vreede WB. Infected cephalhaematomas associated with osteomyelitis, sepsis and meningitits. Pediatr Infect Dis J 1993;12:1015–7.[12] Plauche WC. Subgaleal haematoma: a complication of instrumental delivery. JAMA 1980; 244:1597–8.[13] Chadwick LM, Pemberton PJ, Kurinczuk JJ. Neonatal subgaleal haematoma: associated risk factors, complications and outcome. J Paediatr Child Health 1996;32:228–32.[14] Carey JC, Bamshad MJ, et al. Clinical genetics and dysmorphology. In: Rudolph CD, Rudolph AM, Hostetter MK, et al, editors. Rudolph’s pediatrics. 21st edition. New York: McGraw-Hill; 2003. p. 713–86.[15] Wilkie AO, Slaney SF, Oldridge M, et al. Apert syndrome results from localized mutations of FGFR2 and is allelic with Crouzon syndrome. Nat Genet 1995;9:165–72.
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  33. 33. 946 LOWE WOOLRIDGE[42] Srinivasan R, Arora RS. Do well infants born with an isolated single umbilical artery need investigation? Arch Dis Child 2005;90(1):100–1.[43] Wolf AD, Lavine JE. Hepatomegaly in neonates and children. Pediatr Rev 2000;21(9): 303–10.[44] Nakayama DK, Rowe MI. Inguinal hernia and the acute srotum in infants and children. Pediatr Rev 1989;11(3):87–93.[45] Pulsifer A. Pediatric genitourinary examination: a clinician’s reference. Urol Nurs 2005; 25(3):163–8.[46] Goodman S. Endocrine alterations. In: Potts NL, Mandleco BL, editors. Pediatric nursing: caring for children and their families. 2nd edition. Clifton Park (NY): Thompson Delmar Learning; 2002.[47] Anhalt HE, Neely K, Hintz RL. Ambiguous genitalia. Pediatr Rev 1996;17(6):213–20.[48] Crawford AH. Orthopedics. In: Rudolph CD, Rudolph AM, Hostetter MK, et al, editors. Rudolph’s pediatrics. 21st edition. New York: McGraw-Hill; 2003. p. 2419–57.[49] Gore AI, Spencer JP. The newborn foot. Am Fam Physician 2004;69(4):865–72.[50] Mercuri E, Ricci D, Pane M, et al. The neurological examination of the newborn baby. Early Hum Dev 2005;81:947–56.[51] Stiefel L. In brief: hypotonia in infants. Pediatr Rev 1985;6(9):282–6.[52] Tsao B, Stojic AS, Armon C. Spinal muscular atrophy. E-Medicine. 2006. Available at: http://www.emedicine.com. Accessed August 28, 2007.[53] Morelli JG, Burch JM. Skin. In: Hay WW, Levin MJ, Sondheimer JM, et al, editors. Current diagnosis and treatment in pediatrics. 18th edition. New York: Lange Medical Books/ McGraw-Hill; 2007.[54] Stumpf DA, Alksne JF, Annegers JF. Neurofibromatosis: conference statement. Arch Neurol 1988;45:575–8.
  34. 34. Emerg Med Clin N Am 25 (2007) 947–960 Pediatric Resuscitation Update Stephanie J. Doniger, MD, FAAPa,*, Ghazala Q. Sharieff, MD, FACEP, FAAEM, FAAPb,c a Pediatric Emergency Medicine, St. Luke’s-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025, USA b Palomar-Pomerado Health System/California Emergency Physicians, University of California, San Diego, 3020 Children’s Way, San Diego, CA 92123, USA c Division of Emergency Medicine, Rady Children’s Hospital, 3020 Children’s Way, San Diego, CA 92123, USA The majority of cardiac arrest in children results from a progression ofshock and respiratory failure to cardiac arrest. The goal for resuscitationis to urgently reestablish substrate delivery to meet the metabolic demandsof vital organs [1]. It is important to recognize that successfully applied tech-niques of basic and advanced life support are crucial to reducing neonataland childhood mortality. Currently there are no data on the incidence of pe-diatric resuscitations performed in the United States each year; however, itcan be estimated by extrapolating data from childhood mortality rates(Fig. 1A, B). In 2005, the American Heart Association (AHA) set forth updated guide-lines for Basic Life Support, Neonatal Advanced Life Support (NALS), andPediatric Advanced Life Support (PALS). Overall, the updated guidelinessimplify resuscitation for prehospital as well as for advanced providers.The pediatric age group is now defined to include those children from1 year of age to the onset of puberty. This is determined by the presenceof secondary sexual characteristics that usually occur between 12 and 14years of age. For the lay rescuer, pediatric guidelines are applied to childrenbetween 1 and 8 years old, with adult ACLS guidelines applied to thosepatients older than 8. Once it is recognized that a child needs resuscitation, it is important toapproach the evaluation and management in a stepwise manner. First, theairway is assessed, then breathing, and finally circulation. If there is an ab-normality at any step of this A-B-C assessment, intervention must be * Corresponding author. E-mail address: sjdoniger@hotmail.com (S.J. Doniger).0733-8627/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.emc.2007.07.014 emed.theclinics.com
  35. 35. 948 DONIGER SHARIEFFA Top 10 Causes of Death in the U.S. 1 yr of age (2004) Circulatory System Disease (2.1%) 593 Neonatal Hemorrhage (2.2%) 616Causes of Deaths Bacterial Sepsis (3%) 827 Respiratory Distress (3.1%) 875 Placenta Cord Membranes (3.7%) 1042 Unintentional Injury (3.8%) 1052 Maternal Pregnancy Comp.(6.1%) 1715 SIDS (8%) 2246 Short Gestation (16.6%) 4642 Congenital Anomalies (20.1%) 5622 0 1000 2000 3000 4000 5000 6000 # DeathsB Top 10 Causes of Death in the U.S. 1-18 yrs of age (2004) Benign Neoplasms (0.8%) 178 Septicemia (0.9%) 186Causes of Death Chronic Low. Respiratory Disease (1.1%) 237 Influenza Pneumonia (1.1%) 244 Heart Disease (3.2%) 689 CongenitalAnomalies (5.4%) 1159 Suicide (6.8%) 1471 Malignant Neoplasms (9.2%) 1981 Homicide (9.4%) 2018 Unintentional Injury (43.3%) 9339 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 # DeathsFig. 1. The top 10 causes of death in the United States in 2005 in children younger than 1 year(A), and 1 to 18 years of age (B). (Data from Centers for Disease Control and Prevention/NCHS.2004 National Vital Statistics System, mortality. Available at: http://www.cdc.gov/nchs.)initiated to stabilize the patient. The goal of early, high-quality cardiopul-monary resuscitation (CPR) and defibrillation is to improve overall survivalfrom arrest. Only one third of out-of-hospital cardiac arrest victims receiveCPR before emergency medical service (EMS) arrival [2]. Those who actu-ally receive CPR do not receive enough effective CPR. When CPR is per-formed, suboptimal CPR is often performed with too few, too shallow(37%), and too weak chest compressions. Ventilations (61%) are often ex-cessive, with too many interruptions in chest compressions [3].AirwayEvaluation The first priority in basic and advanced life support is evaluating the air-way. To assess upper airway patency, the provider should look, listen, and
  36. 36. PEDIATRIC RESUSCITATION UPDATE 949feel whether there is adequate breathing. The provider should look for chestrise, listen for breath sounds and air movement, and feel the movement ofair at the nose and mouth. Clinical signs of an airway obstruction includebreathing difficulty, the inability to speak or breathe, poor air exchange,a silent cough, or poor air exchange. It is crucial to determine whetherthe airway is maintainable by simple maneuvers, or not maintainable, neces-sitating advanced interventions [4].Management Simple measures to restore airway patency include positioning, suction-ing, relieving a foreign-body airway obstruction, and the use of airway ad-juncts. More advanced interventions, include endotracheal intubation. Rather than waiting for respiratory arrest, those who do not exhibitadequate breathing should receive rescue breaths. It is recommended totry ‘‘a couple of times’’ to deliver two effective rescue breaths [5]. In thosewho are not breathing, but have a pulse, only respirations should be deliv-ered, without compressions. The health care provider should administer 12to 20 breaths per minute (1 breath every 3 to 5 seconds) for infants and chil-dren, and 10 to 12 breaths per minute (1 breath every 5 to 6 seconds) foradults. Rescue breaths should be given over 1 second, with enough volumeto create visible chest rise. There are no indications stating specific tidal vol-umes, since it is difficult to estimate tidal volumes delivered during rescuebreaths. In fact, much less tidal volume is required during resuscitationthan in normal healthy individuals. During CPR, there is 24% to 33%less blood flow to the lungs. Therefore, fewer breaths with smaller volumesare needed for oxygenation and ventilation [5]. The preferred method of opening the airway for the lay rescuer is thehead tilt–chin lift maneuver for both injured and noninjured victims. It isalso recommended for the health care provider in nontrauma settings. Intrauma situations in which a cervical spine injury is suspected, a jaw thrustmaneuver without a head tilt is recommended to open the airway and main-tain manual stabilization of the head and neck. The jaw thrust is no longerrecommended for lay rescuers because it is difficult to learn and perform,may be ineffective, and may cause spinal movement [6]. In situations of airway foreign bodies, action must be taken in those cases ofsevere airway obstruction. If the individual is unresponsive, it is recommendedto activate EMS and perform CPR. It is unadvisable to perform blind fingersweeps, and it is not recommended to perform the ‘‘jaw thrust’’ maneuver.This technique is difficult, especially for inexperienced providers. The preferredmethod of opening the airway for the lay rescuer is the head tilt–chin liftmaneuver. The recommendation is to perform five back blows and five chestthrusts for infants, and to perform the Heimlich maneuver in older children. In addition, suctioning may be required to further open the airway.Airway adjuncts such as oropharyngeal and nasopharyngeal airways may